Introduction. The management of thoracolumbar burst fractures is controversial. The goal of our study was to evaluate whether the psychological factors or the late spinal deformities influence outcome and in particular quality of life following surgical treatment of burst fractures of the thoracolumbar spine. Material and methods. In a retrospective analysis, we evaluated outcome in 45 patients in whom burst fractures of the thoracolumbar spine without neurological deficits were surgically treated between April 2001 and November 2004. For this purpose, patient charts, surgery reports and x-ray images were analyzed consecutively. 29 patients could be examined physically and the outcome could be evaluated with VAS spine core, quality of life according to short-form 36 (SF36) and Beck Depression Inventory (BDI) with a minimum follow up of 30 months. Results. Mean VAS spine score was 60±26. Neither VAS spine score, nor quality of life results correlated with the following radiological findings: vertebral body angle, sagittal index and height of cranial disc space of the vertebra. Beck Depression Inventory (BDI) correlated with SF-36 score and VAS spine score (p< 0.05). Patients who were depressed showed significantly worse results in relation to the VAS spine score and the SF36 score (p< 0.01). Conclusion. For the first time, we could show, that psychological factors have high influence on functional outcome and health related quality of life in operative treated thoracolumbar burst fracture independent of x-ray findings. Therefore, we recommend inclusion of psychological components in the treatment and outcome-evaluation of the thoracolumbar burst fracture in future

Spinal fractures are common following underbody blast. Most injuries occur at the thoracolumbar junction, and fracture patterns suggest the spine is flexed at the moment of injury. However, current mechanistic descriptions of vertebral fractures are based on low energy injuries, and there is no evidence to correlate fracture pattern with posture at the loading rates seen in blast injury. The T12-L1 segment of 4 human spines was dissected to preserve the paraspinal ligaments and potted in polymethylmecrylate. The specimens were impacted with a 14 kg mass at 3.5m/s in a drop tower; two specimens were impacted in neutral posture, one in flexion, and one in extension. A load cell measured the load history. CT scans and dissection identified the injury patterns. Each specimen sustained a burst fracture. The neutral specimens demonstrated superior burst fractures, the flexed specimen demonstrated a superior burst fracture with significant anterior involvement, and the extended specimen showed a posterior vertebral body burst fracture. At high loading rates, the posture of the spine at the moment of injury appears to affect the resulting fracture. This supports understanding the behaviour of the spine in blast injury and will allow improved mitigation system design in the future

Decision-making regarding operative versus non-operative treatment of patients with thoracolumbar burst fractures in the absence of neurological deficits is controversial, and evidence from trials is sparse. We present a systematic review and meta-analysis of randomised trials comparing operative treatment to non-operative treatment in the management of thoracolumbar burst fractures. With the assistance of a medical librarian, an electronic search of Medline Embase and Cochrane Central Register of Controlled trials was performed. Trials were included if they: were randomided, had radiologically confirmed thoracolumbar (T10-L3) burst fractures, had no neurological deficit, compared operative and non-operative management (regardless of modality used), and had participants aged 18 and over. We examined the following outcomes: pain, using a visual analogue scale (VAS), where 0=no pain and 100=worst pain; function, using the validated Roland Morris Disability Questionnaire (RMDQ); and Kyphosis (measured in degrees). Two randomised trials including 79 patients (41 operative vs. 38 non-operative) were identified. Both trials had similar quality, patient characteristics, outcome measures, rates of follow up, and times of follow up (mean=47 months). Individual patient data meta-analysis (a powerful method of meta-analysis) was performed, since data was made available by the authors. There were no between-group differences in sex, level of fracture, mechanism of injury, follow up rates or baseline pain, kyphosis and RMDQ scores, but there was a borderline difference in age (mean 44 years in operative group vs. 39 in non-operative group, p=0.046). At final follow up, there were no between group differences in VAS pain (25 in operative group vs. 22 non-operative, p=0.63), RMDQ scores (6.1 in operative group vs. 5.8 non-operative, p=0.85), or change in RMDQ scores from baseline (4.8 in operative group vs. 5.3 non-operative, p=0.70). But both kyphosis at final follow up (11 degrees vs. 16 degrees, p=0.009) and reduction in kyphosis from baseline (1.8 degrees vs. -3.3 degrees, p=0.003) were better in the operative group. Operative management of thoracolumbar burst fractures appears to improve kyphosis, but does not improve pain or function

The progressive kyphosis and pain in patients with acute thoracolumbar burst fractures treated conservatively so as the recurrent kyphosis after posterior reduction and fixation were associated to disc collapse rather than vertebral body compression. It depends on redistribution of the disc tissue in the changed morphology of the space after fractures of the endplate. The aim of this study is to evaluate the safety and the efficacy of balloon kyphoplasty with calcium phosphate, alone or associated to short posterior instrumentation, in the treatment of acute thoracolumbar burst fractures. Eleven fractures in ten consecutive patients with an average age of 48 years who sustained acute thoracolumbar traumatic burst fractures without neurological deficits were included in this study. The fractures were A1.2 (3), A3.1 (4) and A3.2 (4), according to AO classification. In 7 fractures (A1.2 and A3.1) the kyphopasty was performed alone in order to make the most of efficacy in fracture reduction, anterior and medium column stabilization and, as much as possible, segmental kyphosis correction. In the A3.2 fractures (4), that are unstable, the kyphoplasty was associated to a short posterior instrumentation. To avoid the PMMA long run complications in younger patients, we used a calcium phosphate cement. VAS, SF-36, Roland-Morris questionnaire (RMQ) and Oswestry low back pain disability questionnaire (ODQ) were used to evaluate pain, state of health, functional outcomes and spine disability. To the average follow-up time of 15.5 months (range 8–31) we did not observe statistically significant differences in 7 of 8 SF-36 domains in comparison to general healthy population of same sex and age. At the same follow-up, the spine disability questionnaire showed a functional restriction of 18% (ODQ) and 29,6% (RMQ) being 100% the maximum of disability. No bone cement leakage, no implant failure and no height correction loss were observed in any case. Our data confirm the safety and the efficacy of ballon kyphoplasty with calcium phosphate in the treatment of acute thoracolumbar burst fractures. In this way we can reduce the possible complications resulted from discal space collapse and obtain an early functional restoration. When performed alone, this mini invasive surgical technique offer the advantage of almost immediate return to daily activities. When associated to posterior instrumentation, it decreases the long run complications and allows to reduce the number of stabilized levels, maintaining, in part, the thoracolumbar junction movement

Aim. Vertebral osteomyelitis (VO) is an infection of the spine mostly caused by bacterial pathogens. The pathogenesis leading to destruction of intervertebral discs (IVD) and adjacent vertebral bodies (VB) is poorly described. We aimed to investigate the connection between infection, bone- and disc-metabolism in VO patients. Method. Fourteen patients with VO (infection group) and 14 patients with incomplete burst fractures of the spine (fracture group as controls) were included prospectively. Demographic data, treatment details, laboratory infection markers, and patient-reported outcome were assessed. Tissue biopsies from affected IVDs and adjacent VBs were analyzed for mRNA-expression levels of 18 target genes including chemokines, adipokines and genes involved in bone-metabolism by RT-qPCR. Results. The Receptor activator of NF-κB/Osteoprotegerin (RANK/OPG) expression ratio was elevated in VB and IVD of the infection group (p<0.001 and p=0.028, respectively). The RANK-ligand (RANKL)/OPG expression ratio was elevated in VB of the infection group (p<0.01). Expressions of the chemokines IL8 and CCL20 were higher in VB samples of the infection group. The expression of leptin was higher in IVD tissue, the mRNA expression of omentin and resistin was lower in VBs of the infection group. OPG mRNA expression was lower in infected VB and in IVD tissue compared to the fracture group. Conclusions. We identified similar expression patterns of pro-inflammatory cytokines and the RANK/RANKL/OPG axis in VBs and IVDs of patients with VO. This finding suggests that common immuno-metabolic pathways are involved in mechanisms leading to tissue degradation in VBs and IVDs during VO

We hypothesised whether MIS techniques confer any benefit when treating thoracolumbar burst fractures. This was a prospective, non-randomised study over the past seven years comparing conservative (bracing:n=27), conventional surgery (open techniques:n=23) and MIS techniques (n=21) for stabilisation and correction of all thoracolumbar spinal fractures with kyphosis of >20. 0. , using Camlok S-RAD 90 system (Stryker Spine). All patients previously had normal spines, sustained only a single level burst fracture (T12, L1 or L2) as their only injury. Age range 18–65 years. All patients in both operatively treated groups were corrected to under 10. 0. of kyphosis, posteriorly only. All pedicle screws/rods were removed between 6 months and 1 year post surgery to remobilise the stabilised segments once the spinal fracture had healed, using the original incisions and muscle splitting/sparing techniques. Patients were assessed via Oswestry Disability Index (ODI) and work/leisure activity status 1 year post fracture. The conservatively treated group fared worst overall, with highest length of stay, poorest return to work/activity, and with a proportion (5/27) requiring later intervention to deal with post-traumatic deformity. 19/27 returned to original occupation, at average 9 months. ODI 32%. Conventional open techniques fared better, with length of stay 5 days, most (19/23) returning to original work/activity, and none requiring later intervention. Average return to work was at 4 months. ODI 14%. MIS group fared best, with shorter length of stay (48 hours), all returning to original work/activity at average 2 months, and none requiring later intervention. ODI negligible. There was no loss of correction in either operatively treated groups. The Camlok S-RAD 90 system is a powerful tool for correction of thoracolumbar burst fractures, and maintains an excellent correction. MIS techniques provide the best outcomes in treating this group of spinal fractures, and offer patients the best chance of restoration to pre-fracture levels of activity

Purpose of Study. Debate exists in the literature about the surgical management of sub-axial cervical burst fractures regarding the approach and types of fixation of these injuries. Our Acute Spinal Injury (ASCI) unit prefers anterior only cervical corpectomy and plate fixation in the management of these injuries. The objective of this study was to radiologically assess the long term outcomes (minimum 2 yrs) of our series. Patients and Methods. Patients were identified using the Acute Spinal Injury Unit (ASCI) database that had had anterior only corpectomy and plate fixation for trauma as a standardised procedure between 2006 and 2009. Initial post-op radiological review included the sagittal alignment, hardware characteristics and surgical technique. Radiological review after a minimum of 24 months involved the union, sagittal alignment, hardware characteristics, graft incorporation and adjacent level degeneration at the site of injury. Results. A total of 51 patients were identified but only 11 were available for review at the minimum 24 months. There were 10 males and 1 female with an average age of 28.1years (18–62). The follow up duration was on average 50.6months (27–71) median 60 months. The levels fused were C3-5 (2), C4-6 (5), C5-7 (3), and C4-7 (1 double level). There was NO metalwork failure, NO screw osteolysis and a varying degree of degenerative changes but a 100% FUSION RATE. The average loss of cervical lordosis was 2.5 ° over the follow up period. Conclusion. Anterior stand alone cervical corpectomy and plating alone appears to be a safe, cost effective and time saving alternative in the management of cervical burst fractures in the sub axial spine with no significant long term complications. NO DISCLOSURES

The aim of this study is to determine evidence-based guidelines on functional outcomes following common thoracolumbar injuries using a synthesis of systematic literature reviews and consensus expert opinion. A questionnaire was created comprising five cases representative of common thoracolumbar injuries (a thoracic compression fracture, a flexion distraction injury and burst fractures each with varied location, patient demographics and treatment strategies). For each scenario five questions about expected functional outcomes were posed. Questionnaires were distributed to the Spine Trauma Study Group. Responses were combined with available data from a systematic review of the same injuries and outcomes to create consensus evidence based guidelines. The survey was completed by 31 (57%) of 53 surgeons representing 20 centres across North America. The systematic reviews identified 49 appropriate studies. One year following a L1 burst fracture, a heavy laborer, treated with protective mobilization (cast or brace) has a 40% chance of being pain free, 70% chance of regaining pre-injury range of motion, can expect to be re-employed within 4–6 months and be able to participate in high impact exercise and contact sport with no or minimal limitation. Length of inpatient stay averages 4–5 days. One year following posterior short segment stabilization of a L1 bust fracture in a college football player, there is an expected 45% chance of being pain free and 55% chance of regaining pre-injury ROM. While an ultimate return to high impact exercise and contact sports is anticipated, 32% of experts expect the injury to end a college football career. Results for the other trauma scenarios are included. This combination of literature and expert opinion represents the best available evidence on functional prognosis after thoracolumbar trauma. By providing consistent, accurate information surgeons and other care path providers will help patients develop realistic expectations, which may shape and improve their ultimate outcome

HIV and musculoskeletal trauma have reached epidemic proportions in the developing world especially in sub Saharan Africa. The epidemic has adversely affected health care delivery in limited resource settings. We assessed the outcome of HIV+ patients following spinal surgery for fractures and dislocations. Forty seven HIV+ patients were treated surgically over the past three years. The mean age was 32 years (19–53 years) and included 39 males. The dorsolumbar region was affected in 28 patients and the cervical spine in 19. Motor vehicle collisions (34) accounted for 72% of the injuries. Neurology occurred in 49% of patients (23). The mean CD4 count was 426 (range 98–742). The albumen was 29 gm/d? (range 26–34) and the lymphocyte count was 1.6c/cumm range 1.4–1.9). Twenty eight patients had generalized lymphadenopathy and recent weight loss was noted in 11 patients. Fifteen patients were treated for pulmonary TB and seven patients were on ARVs. The dislocations at the cervical spine commonly occurred at C5/6 (8). Three patients required a posterior cervical release with facetectomy prior to anterior cervical plating which was performed in all patients. The dislocations and unstable burst fractures of the dorsolumbar spine were treated by a one/two level posterior fusion. Post-operative sepsis due to S. aureus occurred in 8 (17%) patients. In four patients with deep infection vacuum dressings were used to clear the sepsis. Post-operative sepsis is best avoided by optimization of patients and meticulous surgery

In metal-on-metal (MoM) total hip arthroplasty, the taper interface is where the femoral head (female taper surface) attaches to the trunnion (male taper) of the femoral stem. Corrosion is well reported in metal-on-polyethylene hips but little is known about taper corrosion in MoM devices. The aim of this study was to quantify corrosion in modern-generation stemmed MoM hip systems and gain insight into the nature of the underlying corrosive attack. Taper corrosion was quantified in 161 failed MoM components (head components n=128; femoral stem n=33) from nine hip types with the use of a qualitative subjective scoring system. An unanticipated finding on preliminary inspection of the hips was a region on the female taper surface that contained ridges that directly corresponded with the ridged microthread on the trunnion. The ridges were not present on unimplanted (control) female taper surfaces and therefore a novel four-scale subjective scoring system was devised to quantify the prevalence and severity of this ‘imprinting’ phenomenon. Evidence of corrosion was observed in 81% (131/161) of components, with at least moderate corrosion observed in 58% (94/161). Corrosion was greater on the female taper surface than on the male taper (p=0.034) and the two scores were associated (r=0.784, p=0.001). Imprinting affected all manufacturers and was observed in 64% (82/128) of head components. The corrosion and imprinting scores were strongly correlated (r=0.694, p=0.001). Corrosion was largely confined to the area of the female taper interface where imprinting had occurred i.e. the region that had been in contact with the trunnion microthread. Scanning electron microscopy showed evidence of fretting corrosion and substantial mechanical wear within the ridged region on the female taper surface. Our study indicates that MoM hips are susceptible to taper corrosion. We believe it occurs by a process of “mechanically-assisted crevice corrosion,” involving the following sequence of events: joint fluid enters the taper junction as a result of pumping of fluid along the machined microthread of the trunnion. This results in galvanic corrosion of the anodic surface (the cobalt-chromium femoral head or taper sleeve). The pattern of corrosion of the head taper is determined by the surface profile of the screw thread of the trunnion, thus leaving an imprinted appearance. Historically the ridged microthread was introduced to trunnions to minimise the risk of burst fracture of ceramic heads. However this study indicates that the ridges are detrimental in MoM hips by causing extensive mechanical wear. Thus the possibility that cobalt-chrome and ceramic femoral head components require different trunnion designs needs urgent investigation

Robotic assisted spine surgery was a breakthrough in the evolution of spinal surgery, gradually gaining its place as an alternative technique for conventional spinal procedures. As the general population's life expectancy increased so does the incidence of spinal pathology and with it emerged an urging need for a safer and more accurate means of treatment. In our institute we apply the “Spine Assist” platform for a variety of spinal procedures as Vertebroplasties, biopsies, Pedicular screws insertion and an inter-vertebral fusion – GOLIF procedures. This study is designed to analyze the learning curve of each procedure, regarding the amount of fluoro images (FI) taken, fluoro exposure (FE) time and net operation time. All spinal procedures using the “Spine Assist” platform were included in this study; all took place from 2006 until September 2010. Exclusion criteria were procedures with failed pre-op registration, and robotic assisted procedures that were converted to conventional fluoroscopic assisted during the operation. Every single surgery of all types of procedures was analyzed regarding the amount of FI taken, FE time and net operation time. Pedicular screws insertion was grouped into sets of four, where the same parameters were evaluated. Altogether we preformed 106 robotic assisted Vertebroplasty procedures. During this period a distinct learning curve was observed and analyzed. For the first ten Vertebroplasties an average of 12 FI were taken with a net operation time of 53.6 min per procedure. Analyzing the first 40 procedures has shown less FI per procedure (5 FI) and a net operation time of 48.6 min/procedure. Data drawn from the 51 following Vertebroplasties has set the standards of 4 FI with a net operation time of 25.6 min/procedure. Two Vertebroplasty procedures were not completed due to failure of software registration. Pedicular screws are a mean for stabilization of vertebral motion units. During a six years period 706 screws were inserted, out of whom 98 were inserted using percutaneous technique. Comparing the insertion of a set of 4 screws we found a significant improvement regarding the number of FI, FE time and the net operation time between the first ten procedures and the rest with a mean of 20 FI /4 FI and net screw insertion time of 82 min/ 25 min respectively. We found no difference in the parameters comparing percutaneous Vs open Pedicular screws insertion. The mean accuracy of all procedures was 0.3 mm compared to the pre planned screw trajectory. No false route was detected in any of the 506 procedures. This robotic assisted technique is a new and safe approach aiming to shorten the duration of the procedure, thus reducing the patient and surgeon exposure to radiogenic dose. The essence of robotic assisted surgery is a pre planned needle/screw trajectory aiming to reduce the possible intra-operative complication, inaccuracies and possible mishaps emerging during “free hand” procedures. Gaining more experience using the spine assist platform, as shown in this detailed learning curve, enabled us to leverage the platform for ultra-accurate procedures as the percutaneous intervertebral fusion – GOLIF, Vertebroplasty for burst fractures etc